Chuck Grassley

Mr. GRASSLEY

Mr. GRASSLEY. Mr. President, I want to take a few minutes to explain the action I am taking related to S. 1693, the Wired for Health Care Quality Act. Today, with great reluctance, I have asked Republican Leader McConnell to consult with us prior to any action regarding the consideration of this bill, which the Health, Education, Labor, and Pensions Committee reported on August 1, 2007. The Wired for Health Care Quality Act would encourage the development of interoperable standards for health information technology, IT, offer incentives for providers to acquire qualified health IT systems to improve the quality and efficiency of health care, and facilitate the secure exchange of electronic health information. The bill also includes provisions to require all federal agencies to comply with standards and specifications adopted by the Federal Government for purposes determined appropriate by the Secretary of Health and Human Services, HHS, and to ensure quality measurement and reporting of provider performance under the Public Health Service Act. I fully support fostering the adoption of health information technology to assist providers in making quality improvements in our health care system. In 2005, Senator Baucus and I introduced the Medicare Value Purchasing Act, S. 1356, in conjunction with Senators Enzi and Kennedy's legislation known as the Better Healthcare Through Information Technology Act, S. 1355. Although the Medicare Value Purchasing Act did not pass in its entirety, provisions based on our bill have been enacted in other legislation. Medicare is the single largest purchaser of health care in the Nation, so adopting quality payments in Medicare influences the level of quality in all of health care. We have seen time and time again how when Medicare leads, the other public and private purchasers follow. Medicare can drive quality improvement through payment incentives. The adoption of information technology is also desirable, both to facilitate the reporting of quality measures and to increase the efficiency and quality of our health care system. These two concepts should work together. A number of legislative initiatives have been enacted in Medicare in recent years to promote the development and reporting of quality measures. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, MMA, included provisions that required the reporting of quality measures for inpatient hospitals. The Deficit Reduction Act of 2005 expanded the reporting of quality measures for inpatient hospital services and extended quality measures to home health settings. Last year, the Tax Relief and Health Care Act of 2006, TRHCA, extended quality measure reporting to hospital outpatient services and ambulatory service centers. TRHCA also authorized the 2007 Physician Quality Reporting Initiative, PQRI, a voluntary quality reporting system in Medicare for physicians and other eligible health care professionals. Beginning July 1, 2007, the new PQRI program provides Medicare incentive payments for the successful reporting of quality measures that have been adopted or endorsed by a consensus organization. The Centers for Medicare and Medicaid Services, CMS, has worked diligently with the American Medical Association Physician Consortium for Performance Improvement, the Ambulatory Quality Alliance, and the National Quality Forum in the development, adoption, endorsement, and selection of quality measures for this program. Considerable time and effort have been devoted to the development and reporting of quality measures for various providers in Medicare under the Social Security Act. Many of these programs have now been up and running for some time. This is why I am greatly troubled that, as currently drafted, the Wired for Health Care Quality Act would require the development and reporting of quality measures under the Public Health Service Act. It is hard to comprehend how the quality measurement system created by S. 1693 would interact with the various quality measurement programs that have already been enacted by Congress under the Social Security Act and implemented by CMS. Creating two different quality measurement systems would have the potential to create differing or even duplicative quality measurement systems which could drastically interfere with our common goal of improving the quality of health care in this country. Under the bill, the Secretary also would establish Federal standards and implementation specifications for data collection. Within three years of their adoption, all Federal agencies would have to implement these standards according to the specifications. While this sounds appealing, I am concerned about the reality of implementing such standards--across the myriad programs at the Departments of Health and Human Services, Veterans Affairs, Defense, and all the other Federal agencies that may have health care data. It would be an enormous challenge. Agencies collect data for many different purposes, using many different data systems. Six years ago, when Secretary Thompson first arrived at the Department of Health and Human Services, the department had eight different computer systems. Presumably other agencies similarly have multiple systems. All will be expensive and difficult to retrofit to meet new federal standards. The bill also would require the HHS Secretary to provide federal health data, including the Medicare claims databases, to at least three ``Quality Reporting Organizations'' that agreed to provide public reports based on the data. The Quality Reporting Organizations would be required to release regular reports on quality performance that are provider- and supplier- specific. Any organization, including those with commercial interests, could request that the Quality Reporting Organizations compile specific reports based on the requester's methodology. So, for example, drug companies could request data on physician prescribing patterns to determine which physicians their salespeople should target. In overseeing Medicare, Congress is working to bring more quality reporting into the program. As I mentioned before, just this past December Congress enacted the Tax Relief and Health Care Act of 2006, which implemented a physician pay-for-reporting program in Medicare. The Finance Committee has been working for some time now to phase-in the use of quality measures with various providers. Eventually, I hope that Medicare can compensate providers appropriately for providing high-quality care. I am, however, concerned about public disclosure of provider-specific information without appropriate safeguards. If not used properly, the data could be misinterpreted. For example, hospitals that specialize in very difficult cases might seem to provide lower quality of care than those treating less severe cases. This would set up the wrong incentives for hospitals and other health care providers. I agree that it would be helpful to standardize data reporting throughout the federal government, and to use that data appropriately to assess the quality of care provided by clinicians, hospitals, and other health care organizations. At the same time, I have serious concerns about how this bill is structured with respect to the disclosure and use of the data from federal health entitlement programs which are within the sole jurisdiction of the Finance Committee. I welcome the opportunity to work with the sponsors of S. 1693, Senators Kennedy, Enzi, Clinton, and Hatch, along with members of the Health, Education, Labor, and Pensions Committee on this matter. I had hoped we could work out an agreement on legislative language that was acceptable to both the Finance Committee and the HELP Committee before the bill was on the floor. I appreciate the efforts that my colleagues, Senators Enzi and Kennedy, have undertaken with us over the last month to resolve the concerns of the Finance Committee. However, I remain deeply troubled that, as currently drafted, the Wired for Health Care Quality Act could end up unintentionally delaying or frustrating the goal we all share of improving the quality of health care for all Americans.

Mr. GRASSLEY

Mr. GRASSLEY. Madam President, I would like to take a few minutes today to discuss an important issue that affects all Americans who take prescription drugs. Specifically, I am going to speak about the need for greater transparency in the payment that doctors who bill Medicare and Medicaid receive from drug companies. Over the past few years, it became apparent during my inquiries into the Food and Drug Administration that drug companies pay physicians for a variety of different reasons. Indeed, some of our leading physicians--doctors who have significant influence in their medical fields--receive tens of thousands of dollars every year from drug companies. For some, these payments can make up a considerable amount of their annual income. The payments can take the form of honoraria for speaking engagements, payments to sit on advisory panels, and funding for research. Further, drug companies spend about $1 billion a year to fund educational courses that doctors are required to take every year called Continuing Medical Education, or CME. In April, the Finance Committee staff prepared a report on pharmaceutical companies' support of Continuing Medical Education. This report found that some educational courses supported by drug companies have become veiled forms of advertising that encourage off-label use of drugs. Let's review how this works. Right now, it is possible for a doctor to attend a CME--continuing medical education--course sponsored by a drug company. That same company can make payments to doctors who will teach the course, and the doctor who teaches the course can discuss the findings of research paid for by the company. Now, that may sound like a conflict and unethical, but that is how it happens. The whole field is connected by a tangled web of drug company money. To try and understand this a little better, I have been exploring the money doctors get from drug companies, especially the doctors who work as academic researchers. Most universities require their academic researchers to report outside income. I have sent letters to a handful of universities to understand how well such a reporting system actually works. I haven't received all the information yet, but I can comment on some of the things I have already found. Most universities require professors to report outside income that may create a conflict of interest with their research. This means that if a doctor at a university is receiving money from a company either for research, speaking fees or to sit on an advisory panel, then they have to report that income. But there appears to be a couple of problems, and let's say a couple of problems with the whole system, as I found out. The only person who knows if the reported income is accurate and complete is the doctor who is receiving the money. The university doesn't necessarily police its own people to make sure they are reporting everything they are supposed to report. It seems that some of these academics are getting so much money coming in from so many different companies they need an accountant to be sure everything is reported accurately. Second, these disclosures are usually kept secret. So if there is a doctor getting thousands of dollars from a drug company, payments that might be affecting his or her objectivity, the only people outside the pharmaceutical industry who will probably ever know about this are the people at that very university, if they are even keeping track of it, and we don't know that they are keeping track of it. But most Americans never get a fair chance to see this information. To give one example, I sent a letter to the University of Cincinnati asking about how much money the drug companies have been paying one of their psychiatrists, Dr. Melissa DelBello. Back in May, The New York Times reported on the research done by Dr. DelBello to see if adolescents could be treated for bipolar disorder with a powerful drug called Seroquel, which is manufactured by Astra Zeneca. The study was funded by Astra Zeneca and showed that Seroquel was a good choice for treating bipolar disorder in children. Dr. DelBello's study was later cited by a prominent panel of experts who concluded that drugs such as Seroquel should be a first-line treatment for children with bipolar disorder. Here is where it gets interesting. After Dr. DelBello released her study, Astra Zeneca began hiring her to give several sponsored talks. Another doctor told The New York Times he was persuaded to start prescribing drugs such as Seroquel after listening to Dr. DelBello. But when the reporter from the New York Times asked Dr. DelBello how much money she got from Astra Zeneca, she told the paper: ``Trust me. I don't make much.'' Well, I decided to find out how much, and I went directly to the University of Cincinnati who, by the way, has been extremely cooperative, helpful, and responsive. Soon I figured out just how much ``not that much'' money is. Dr. DelBello's study, which helped put Seroquel on the map, was published in 2002. That next year, she got more money than she has ever received from the pharmaceutical companies--at least that is what the documents that I have say. In 2003, Astra Zeneca alone paid her a little over $100,000 for lectures, consulting fees, travel expenses, and service on advisory boards. In 2004, Astra Zeneca paid her over $80,000 for the same services. Now I am not saying this money was a payoff or suggesting there is something inherently bad with accepting drug company money, but let me tell you what Dr. Steven E. Hyman, provost, Harvard University and former Director of the National Institute of Mental Health, said. He said these payments could encourage psychiatrists to use drugs in ways that endanger patients' physical health. Specifically, he said of doctors: We don't connect the wires in our own lives about how money is affecting our profession and putting our patients at risk. I think this is a rather interesting assessment by Dr. Hyman. But let me continue. Just last March, several leading physicians released a study on pharmaceutical company payments to physicians. They published this study in the Journal of the American Medical Association, one of the most prestigious journals in medicine. I would like to quote what they concluded about the need to provide public disclosure of these payments to doctors: Full disclosure would better allow the public to appreciate the relationship between industry and the health profession. And so, for the sake of transparency and accountability, shouldn't the American public know who their doctor is taking money from? After all, anybody can go on the Internet and see who is funding the campaigns for federally elected officials. Because doctors are expected to look out for the health and well-being of their patients, shouldn't we hold doctors to similar standards? In fact, some of this is already occurring. Minnesota requires drug companies to report any payments they give to doctors in that State. I think that is a good thing. Apparently, so do the citizens of Minnesota. I think what we really need is a national program that will require all drug companies to report when they make payments to doctors. I don't think it would be all that hard for those companies to do. After all, companies have to make sure they know where every penny is going. So it should not be that hard to report some of it to the Federal Government and to the American people. Besides, they are already doing it in Minnesota. In closing, I plan to continue my inquiry into drug company payments to doctors. In addition, I look forward to working with my colleagues in the Senate, as well as members of the pharmaceutical industry, to establish a national reporting system. I yield the floor.

Mr. GRASSLEY. I ask unanimous consent that the order for the quorum call be rescinded.

Mr. GRASSLEY

Mr. GRASSLEY. Mr. President, as my colleagues have stated, we have to make health insurance more affordable. One thing Democrats and Republicans can agree on is that there are inequities in the tax treatment of health insurance. We all agree that Congress should level the playing field and expand access to health insurance; the question gets down to how. Proposals which have been introduced so far include the President's proposal, which includes a standard deduction for health insurance. Senator Burr, Senator Coburn, Senator Martinez, Senator Corker, and Senator Dole have formally introduced a tax credit proposal. Each proposal contemplates eliminating the exclusion for employer-provided coverage to meet this end. Currently, a taxpayer who receives health insurance through his or her employer is not taxed on the cost of the health coverage. Individuals who do not receive health coverage through their employer and are not employed and purchase health insurance on the individual market generally do not receive a tax benefit. As we just discussed, this problem is most acute in the small business context. Senator Wyden and Senator Bennett are also interested in fixing the health care system and making health insurance more affordable. Their proposal also contemplates amending the Tax Code for that purpose. I commend Senators Wyden and Bennett for their work in this area. I wish to ask Senator Burr if he would take an opportunity at this time to comment on this and explain where he is coming from, and then I will call on Senator Bennett.

Mr. GRASSLEY. I would also like to thank my colleagues for their leadership on this issue. I share your concern with the diabetes epidemic in the United States and especially the effect it is having on our Native American communities. I support the reauthorization of the Special Diabetes Program for Indians and also the reauthorization of the Special Funding Program for type I diabetes research. The prevention and treatment of diabetes has improved greatly over the past decade. These programs have clearly played a major role in these improvements. I also look forward to working with my colleagues to reauthorize these programs during this Congress.

Mr. GRASSLEY. Mr. President, I ask unanimous consent for possibly 10 minutes to have Senator Burr, Senator Bennett, and myself engage in a colloquy.

Mr. GRASSLEY. I am going to not say any more, but I ask unanimous consent for 3 additional minutes, and then I will be done because there are three other Members whom I forgot to mention whom I promised a minute to.

Mr. GRASSLEY. I yield 1 minute to Senator Corker and then 1 minute to Senator Martinez and then 1 minute to the Senator from Oklahoma, or whoever wants to use the last minute.

Mr. GRASSLEY. Mr. President, the underlying intent of any of these proposals is to put downward pressure on insurance costs, thereby reducing the cost of health care. If Congress goes in the direction of a tax credit, the tax credit must be structured so that low-income individuals have a meaningful tax subsidy to purchase health insurance. If Congress goes in the direction of a standard tax deduction, any deduction must be structured to ensure that taxpayers who continue to receive health care coverage through their employer do not see a significant increase in their taxes. Congress should also contemplate a combination of a tax credit and a deduction. A combination effectively marries these tax concepts and may serve as a viable compromise. I believe that the Senate Finance Committee should hold hearings on the various ways we can reform the health care system. We may even be able to mark up a proposal that could be acted upon by this body before the end of the year. I yield the floor.

Mr. GRASSLEY. Mr. President, how much time remains?

Mr. GRASSLEY

Mr. GRASSLEY. I ask for the yeas and nays.

Mr. GRASSLEY

Mr. GRASSLEY. Mr. President, I ask unanimous consent to speak for such time as I might consume.

Mr. GRASSLEY

Mr. GRASSLEY. Mr. President, before I go to further remarks, I want to give some credit on the passage of H.R. 976 the bill we just had and the cooperation. The Grassley-Baucus cooperation has been mentioned here. I really compliment Senator Baucus for his leadership in working with us. But, also, it took us 3 or 4 months to put together a bill, and Senator Hatch and Senator Rockefeller were very much involved in that effort with many long hours. So I thank them. I do wish to make the point that what the Senate has done over the past few days has genuinely served the interests of the American people. The Senate passed this bipartisan legislation which will cover an additional 3.2 million children. The Senate has proceeded in regular order to process amendments. Every amendment that was offered was defeated--I mean every one on which we had a rollcall vote was defeated. So this bill basically has come out of the Senate the same way it came out of the Senate Finance Committee. This is how we should do business in the Senate. Amendments were debated and voted upon. Members had the opportunity to consider a variety of changes to the Senate Finance Committee bill. Some were adopted by voice vote. Those that took a rollcall, none of those were adopted. But regular order was followed, and the Senate worked its will. I am pleased with the Senate Committee product, which is a bipartisan product. I am also pleased with how the majority and minority leaders have handled the process. This has been a tough, complicated piece of legislation. A lot of Members and staff have worked very hard to get us to this point. I thank the chairman for his tireless efforts and how he worked in a bipartisan manner. I wish to thank his staff: Alice Weiss, Michelle Easton, Bill Dauster, Russ Sullivan, David Swartz, and Rebecca Baxter. I also thank Senator Rockefeller and his staff: Jocelyn Moore and Ellen Doneski. Much is also owed to the Senator from Utah, Mr. Hatch, and his staff. Finally, I wish to thank the staff of the minority--I should say the Republicans on the Finance Committee: Chris Condeluci, Mark Prater, Becky Shipp, Rodney Whitlock, Mark Hayes, and Kolan Davis. Now, I would like to address the Senate since we passed our bill, since the House last night passed their bill, and soon there will be a conference between the House and Senate. I wish to speak about some things I think the House of Representatives has done that are damaging to Medicare Advantage. People are saying that Medicare Advantage plans are overpaid. They talk about cutting payments, and that is what the House of Representatives has done in their SCHIP bill. But they do not talk about why Congress set up the payment structure, which was to create choices of plans in Medicare and to expand private plan choices in rural America. They do not talk about why Congress set up that choice. It worries me that those arguing about the plan payments are losing sight of the Medicare beneficiaries. These beneficiaries, the seniors and disabled of America, are the ones who benefit from having Medicare Advantage plans available to choose from. Congress, in 2003, enacted the Medicare Modernization Act. That is the act that included the prescription drug program as an improvement in Medicare. A major goal of the MMA, the Medicare Modernization Act, was to expand beneficiaries' choice of Medicare plans. Before MMA, rural beneficiaries, such as my people in Iowa and a lot of States that are more sparsely populated than Iowa, rarely had a private Medicare plan to choose from. Now rural and urban Medicare beneficiaries can decide whether a private plan option or traditional Medicare works best for them. I want to tell you why Medicare Advantage can be a good option for beneficiaries and why the program should not be touched, as it was recently by the House of Representatives in their SCHIP bill. I want to explain at the same time why Congress thought all beneficiaries, whether you were in rural America or urban America, should have a choice of plans. The original Medicare benefit is set up based on how medicine was practiced in 1964, meaning in 1964 the fee for service that is the traditional Medicare was set up at a time when you went to the doctor. If you were very sick, then you went to the hospital. Medicine was much less specialized. Patients were treated by one doctor at a time, not the teams of people who treat patients now. Under traditional Medicare, dating from 1964, hospital benefits are in Part A of Medicare; physician benefits are financed and delivered separately in Part B of Medicare. Each set of benefits has its own deductible. A hospital deductible alone is a lot higher than most working people have in their health insurance. It is $992, and it goes up a little bit every year. That is a pretty significant amount. That deductible alone can impose a big hardship on a family, if they are relying solely on Medicare for their health coverage. Medicare also only covers a limited number of hospital days each year. It is not great protection if you are severely injured or if you have an illness that has a long hospital stay. Say you happen to end up in the hospital for months at a stretch, you might end up exhausting your Medicare coverage. A lot of people don't realize how limited Medicare benefits can be. Medicare also does not actually have catastrophic coverage. Traditional fee-for-service Medicare, the Medicare since 1964, by itself does not provide protection against the cost of catastrophic illness. Some beneficiaries then buy Medigap insurance for this catastrophic insurance. Medigap insurance can be expensive for those on fixed incomes. In contrast, and hence why the House of Representatives should not change Medicare Advantage, Medicare Advantage plans have catastrophic coverage for those seniors who want to choose it, and they do it for a much lower premium than the Medigap add-on to traditional fee-for-service Medicare. That is one of the many reasons Medicare Advantage should be an option, not just in metropolitan areas, as it was before we passed the prescription drug bill in 2003. We need rural equity. And through the MMA, we brought rural equity so that people in my State and more sparsely populated States can have a choice between fee-for-service Medicare and Medicare Advantage, which can be a preferred provider organization, HMOs, or fee-for-service Medicare Advantage. Prior to 2003, in my State of Iowa, only 1 of 99 counties had the Medicare Advantage option. That was Pottawatomie County right across the river from Omaha, because they could work in with Omaha, but the other 98 counties did not have choice as they have in Los Angeles and Texas and Arizona, New York and New Jersey, Philadelphia, and Florida. There may be some others but not really rural States. You are stuck with fee-for-service traditional Medicare written in 1964, not much for the practice of medicine in the year 2007. So I am very concerned that what the House of Representatives did in their SCHIP bill is such that it is going to put in danger the choices we now have in rural America between fee-for-service traditional Medicare and Medicare Advantage such as some of the more metropolitan States have had for a couple decades. If you are in Medicare Advantage, you don't have to have the Medigap add-on to your traditional Medicare. Another plus is that most Medicare Advantage plans also have a limit on out-of-pocket costs. In Iowa the plans often have a limit of $1,000 or less. In other States, Montana, much of New York and California, that is true as well. In some States and counties, out-of-pocket limits are higher. Traditional Medicare has no out-of-pocket limits. In original Medicare, to keep costs down, Congress imposed caps on types of care. For example, there is a $1,780 annual cap on physical therapy. Once a patient hits that cap on physical therapy, he must pay out of pocket if he needs more therapy, unless he gets approved for an exception. Many patients hit the cap early in the year. These are patients who have had a stroke or a serious accident. After that they have to pay themselves for the service unless they succeed in appealing for more therapy services. Then by contrast, Medicare Advantage plans can base coverage for physical therapy on what the patient needs, not what some bureaucrat in Washington says there is a limit on. They can avoid these arbitrary caps. In original Medicare, patients may see a doctor whenever they like. That may seem like a good idea. Many patients see a lot of doctors and are prescribed many different drugs. In original Medicare, physician care can be disjointed. No one oversees all the care a patient receives. Some patients prefer it that way. Others welcome having help navigating the health care system. They would like to choose a plan that would help them coordinate their care, and most Medicare Advantage plans do just that. So that is why we don't want the House of Representatives to cripple Medicare Advantage. Let's say a patient has diabetes. In Medicare fee for service, there is no one to help monitor that she is testing her blood sugar. No one checks to see if she is getting her eyes and feet checked, which are the result of diabetes. And in most Medicare Advantage plans, somebody does that oversight. Somebody does that checking. Plans use teams of people, ranging from doctors to pharmacists to nurses to dieticians to case managers, all to make sure enrollees are getting the care they need. Four out of five Medicare beneficiaries have a chronic illness. In many Medicare Advantage plans, one doctor oversees their care. The plan assigns a case manager. Patients don't have to navigate the system alone. For many patients, this can be preferable, and it is because of Medicare Advantage. We don't want that plan crippled, as the House of Representatives bill does. Medicare Advantage is a great program for poor and low-income people. Critics of the program argue that poor people qualify for Medicaid. They say Medicare Advantage doesn't help them. I want to make it clear that this is not true. I am going to get to that point later. But even the critics cannot argue with the statistics about lower income or near poor beneficiaries. These beneficiaries can't afford a Medigap policy. For them, Medicare Advantage is a godsend. According to the Centers for Medicare and Medicaid Services, the average Medicare Advantage beneficiary gets $86 a month in extra benefits. Most of those extra benefits are in reduced cost sharing. Medicare Advantage plans often reduce copays and deductibles that beneficiaries otherwise would have to pay. As I noted, Medicare Advantage plans offer catastrophic coverage. If an enrollee ends up in the hospital for weeks or even a year, the plan covers it. That is not true of traditional Medicare fee-for-service, started in 1964. It doesn't fit the practice of medicine today. But Medicare Advantage offers medicine delivered on the practice of medicine in 2007. The benefits may include an annual physical. They may include lower copays for enrollees needing kidney dialysis. They include unlimited physical therapy based upon patient need. Ninety-nine percent of the beneficiaries have access to a Medicare Advantage plan that plugs the gap in the Part D drug coverage; 98 percent have access to a plan that offers preventive dental benefits. Beneficiaries in Medicare Advantage plans are more likely to get preventive services. Almost all Medicare beneficiaries have access to a plan with no-cost cancer screening. And for this, many beneficiaries pay no extra premium. They pay only the regular Part B premium, as everybody else does. Eighty-four percent of beneficiaries had access to a zero premium Medicare Advantage plan last year. Many seniors live on fixed incomes. Medicare Advantage may be the only way they can afford these benefits. It is also easy to use. Many Medicare Advantage plans let seniors use one health care card, their Medicare Advantage plan card, for all of their health care needs. Instead of three cards, they have one card. They pull the same card out when they go to the doctor, same card they use for the hospital, the same card they use for the pharmacist. They don't have to worry about dealing with claim forms from two or three different insurance plans. But that is not the case for beneficiaries in the original 1964 type Medicare. If they have Medigap and Part D prescription drug coverage, they have to deal with multiple plans that don't coordinate their coverage or coordinate their benefits. I said I would get back to why Medicare Advantage is good for lower income seniors. It is true that many lower income beneficiaries are also covered by Medicaid. These individuals are referred to as dual eligibles, because they are under both Medicare and Medicaid. But we have a program in Medicare Advantage for people who are eligible for both. This program is called a special needs plan. It coordinates the care and the benefits between the Medicaid Program which is run by the States and the Federal Government. It should be seamless to the beneficiaries. Have these special needs plans worked perfectly? Not always. The program is a work in progress. Surely it is a lot better than what happens without it. Without it, health care for poor beneficiaries is siloed. The parts covered by Medicare are never coordinated with the parts Medicaid is responsible for. Let's say a frail senior is in a nursing home. She has exhausted her savings so Medicaid is paying. She has Medicare for her health coverage. She enrolls in one of these special needs plans. When she gets a fever or an infection, the Medicare Advantage special needs plan can treat her at the nursing home. In the original Medicare, the nursing home would send her to the more expensive hospital environment. The hospital, after 3 days, would discharge her to a skilled nursing home facility. For her, the Medicare Advantage plan reduces disruptions and keeps her from being exposed to additional infections in the hospital. At the same time, you save a lot of money in Medicare. Both she and Medicare are spared the cost of hospitalization--the most expensive health delivery. So the critics who say that Medicare Advantage is not helping poor people are mistaken. While the program is small, that is because the program is new. It can be a model for all of us. This is how we want our care to be delivered to us when we are very old and when we are very frail. So Medicare Advantage can be a good choice for very sick people. It can be a good choice for people with chronic illness. It can be a good choice for lower income people. It can be a good choice for people who want some extra benefits. It can be a good choice for people on fixed incomes. It can be a good choice for rural beneficiaries as well as urban ones. When the House of Representatives gets done with it all, we will not have it in rural America. But they will still have it in urban America, and that is very unfair. That inequity was meant to be taken care of when we passed the prescription drug bill in 2003, and I am not anxious to let that sort of equity between rural and urban America go away. But it can also be a good choice for seniors. All Medicare beneficiaries, whether they live in a city, a small town, or on a farm, ought to be able to choose their own plan. They know best what suits their needs--the original 1964 Medicare or the 2003 Medicare Advantage plan. The House bill would gut the Medicare Advantage program. It would take these choices away from our beneficiaries. The Senate SCHIP bill avoids this. I urge my colleagues to remember why we decided to give Medicare beneficiaries a choice of health plans. I urge my colleagues to reject efforts to cut Medicare Advantage. I yield the floor.

Mr. GRASSLEY. No. I am going home.

Mr. GRASSLEY. I thank the Senator for listening to me.

Mr. GRASSLEY

Mr. GRASSLEY. I thank Senator Baucus for taking the time today to shed some light on implementing the limited tax benefits standard. I look forward to working with the chairman as we proceed.

Mr. GRASSLEY. I thank the distinguished chairman, my friend from Montana, for initiating this important discussion. I would like to put this discussion into a broader historical context. For over 20 years, chairmen of the Finance Committee have employed a practice of opposing narrow tax provisions, commonly known as ``rifleshots.'' The legislative change we will discuss in some detail is really a formalization of the practice the Finance Committee has maintained over the past two decades.

Mr. GRASSLEY. Madam President, I am rising to speak against the compromise that deals with the issue of secret holds. I would agree with the Senator from California, the distinguished chairman of the committee, that what we have in this report is probably better than what we have today because secret holds are secret, and nobody knows who is holding a bill. The public's business ought to be public, and it isn't today. But I do take exception to what is before us in regard to secret holds for the simple reason that there wasn't any necessity whatsoever to compromise. Secret holds are rules of the Senate, or procedures in the Senate, and this body spoke with 84 votes in favor of what Senator Wyden and I put before the Senate. Basically, this makes it so liberal that it is practically meaningless what we are doing about secret holds. Article I, section 5 of the Constitution of the United States reads in part: Each House may determine the rules of its proceedings. That means that the House of Representatives would have no say whatsoever in the Senate rules, but a conference was used for negotiations between the House and Senate. That was used as a rationale for changing what Senator Wyden and I had previously gotten passed in the Senate. So when the Senate debates and passes changes to its rules, that ought to be the final word. But that wasn't the final word, as we are seeing today. That is what happened with the House package of rules changes that the body passed in the Congress, and we didn't attempt to tell the House what they ought to do. However, since the ethics reform bill that the Senate passed in January also contained changes to the Lobbying Disclosure Act and other laws, the entire bill needs to pass both Houses of Congress and be signed by the President. Nevertheless, that does not change the fact that under the Constitution, only the Senate determines its rules and procedures, and the Senate, in an overwhelming majority, spoke. So why shouldn't it be left just the way Senator Wyden and I had originally introduced it. What has happened is, the Senate had a full open debate about it and passed the changes that we did in Wyden-Grassley. Now we have a situation where the majority leader of the Senate and the Speaker of the House rewrote major provisions in this package, including rewriting Senate rules that had already passed the full Senate. In conference, one provision that was changed was a provision that I referred to which Senator Wyden and I had been working on for years to end the practice of secret holds because the public's business ought to always be public. Any Senator who has guts enough to put a hold on a bill ought to be willing to stand up and say who they are. Only in the Senate can a single Member prevent legislation or nominations from being considered under the so-called procedure of holds. Holds do not exist in the House. Senator Wyden and I were successful in passing an amendment in last year's ethics reform bill by a vote of 84 to 13 on public disclosure. That same language was included in the bill without a vote in this Congress. But you know how things go on around the Senate. We had prominent Senators, people who run this body, who told Senator Wyden and I that ``they get the message,'' after 6 or 7 years, and, finally, we were going to end this secrecy. That bill wasn't enacted, but we included those identical provisions in this bill. Senator Wyden and I pushed for that provision because we believed the public's business ought to be done in public. Every Senator has the right to object to a unanimous consent request to proceeding to a matter. Senators have every right to object to a unanimous consent request publicly, but I see no legitimate reason Senators should be able to be secret about what they are doing in the Senate. It has been my policy for years to place a brief statement in the Congressional Record each time I place a hold, with a short explanation of why I placed that hold. It has never hurt me one bit, and Senators should have no fear following a requirement of the public's business being public. In other words, nothing secret. If you want to hold up a bill, just have guts enough to say so. So I say the Senate has spoken in passing our very well thought out provision. And I should add that this provision was written with the help and advice of Senator Lott and Senator Byrd, both former majority leaders with much valuable insight about how the Senate works. Yet even though the Senate has already spoken as a body on this matter, a single Senator has single-handedly rewritten part of this provision, overriding what I consider overwhelming support in the Senate to end secret holds. In the version that was Senate passed, we allowed 3 days for Senators to submit a simple public disclosure form for the Record, just like adding your name as a cosponsor to a bill. The intent is not that it is somehow legitimate to keep a hold secret for 3 days, but we wanted to give Senators ample time to get their disclosure to the floor to be entered into the Record. The rewritten provision, as Senator Feinstein has said, gives Senators 6 legislative days instead of those 3 days. It is absurd to think that Senators need over a week to send an intern down to the floor with this simple form. Of greater concern is that the rewritten language requires Senators to disclose a hold only after a unanimous consent request is made and objected to anonymously on the Senator's behalf, and then they have 6 days after that. That is too late. By that point, particularly at the end of a session, it is going to make this process meaningless. By that point, a hold could have existed for some time, perhaps without the sponsor of the bill even realizing it. Furthermore, since the majority leader controls the Senate's schedule, he would hardly object to his own request to bring up a bill or nominee. He would simply not bring up a bill or nominee being held up by a Member of his own party. If a Member of the minority party were to attempt to ask unanimous consent to proceed to a matter, he would object on his own behalf to protect the majority leader's prerogative to set the agenda, and any secret holds by members of a majority party would remain secret. I am deeply disappointed that this provision that Senator Wyden and I worked so hard on, over a period of at least 6 years, to finally get a vote of 84 Members of this body supporting it, and then, because it was almost a fait accompli as seen by leaders of this body--powerful Senators in this body--just to put it in, in January, in the bill that is before us because it would be done--so-called ``getting the message,''--well, who has forgotten that they got the message that they had to change this? And that is what is so irritating. I am going to vote for this bill, but this was something that didn't need to be in a bill. It didn't need to be negotiated. This was decided by the vast majority of the Senate. But you know what it tells me. There are still people around here who don't want the public's business to be public. They want to do things in secret. They do not have guts enough to say they want to hold up a bill. So we end up with this convoluted thing we have of 6 days, but it isn't even kicked in until after there is an attempt by somebody to ask for a unanimous consent request to bring up a bill, and then only at that point, and then there is 6 days after that. So I have stated my piece. I am not very happy. I hope Senator Wyden is as unhappy as I am and will try to do something in the future.

Mr. GRASSLEY. That would be 10 minutes.

Mr. GRASSLEY. Also, on behalf of Senator Stevens, because he was waiting to claim his time, and he had to go to a markup, he asked if I would have his name taken off the list and reserve the time for our side. But I would ask unanimous consent that I have 5 of that 10 minutes he originally had added to my time.

Mr. GRASSLEY. We are not going back and forth?

Mr. GRASSLEY

Mr. GRASSLEY. Mr. President, I am pleased to join my good friend and colleague Senator Baucus to introduce the Continuing the Advancement of Quality Improvement Act. The purpose of this legislation is to reform Medicare's troubled Quality Improvement Organization, QIO, program. QIOs and their predecessor organizations have long been responsible for ensuring that the care Medicare beneficiaries receive is medically necessary, meets recognized standards and is provided in appropriate settings. They are currently tasked with a wide variety of important roles ranging from investigating beneficiary complaints of poor quality care to giving technical assistance to Medicare providers for improving health care quality. I have been an advocate of reforming the QIO program for quite some time. About 2 years ago, I initiated an investigation into a number of the QIOs. Those investigations revealed a program that is in desperate need of reform. This program was running with little or no oversight, and it was expending more than $1 billion every 3 years with little measurable results. In other words, I found trouble. Let me elaborate on a few disturbing things that I discovered. I found that one QIO leased residential properties for board members and a CEO. That same QIO also used Federal funds to lease automobiles for its top executives. I also found other QIOs who had board members and staff attend conferences, many at lavish resorts. I was not the only one to identify serous concerns with the QIOs. Others identified concerns too. Specifically, the Institute of Medicine, IOM, the General Accountability Office, GAO, and the Department of Health and Human Services, HHS, Office of the Inspector Geheral (OIG) all identified numerous concerns about the effectiveness of this program. These independent organizations also voiced their concerns with the manner in which it is operated and have made recommendations for major reform. Their findings clearly show the need to hold the Centers for Medicare and Medicaid Services, CMS, and the organizations that serve as QIOs accountable for the important tasks they must perform. The Continuing the Advancement of Quality Improvement Act will ensure that the QIO program is not only effective in improving the quality of care provided to our Medicare beneficiaries, but also that it operates in an effective, efficient and accountable manner. Much of this legislation is based on the investigations that I conducted and the troubling findings that I came across and on the work of the IOM, the GAO, and the HHS OIG. First, the Continuing the Advancement of Quality Improvement Act would focus the mission of the QIO program on quality improvement. QIOs currently have many diverse responsibilities. As a result, they served conflicting roles of both ``regulator'' and ``technical assistant.'' This conflict poses significant barriers to QIOs effectively serving either role, and we have come to learn that they really don't perform either function particularly well. The legislation would also address this conflict by following the IOM's recommendation to make the sole purpose of QIOs to be technical assistants for quality improvement and performance measurement. The HHS Secretary would be required to transfer all other QIO: responsibilities to other entities called Medicare Provider Review Organizations, MPROs, in a manner that will support the needs of beneficiaries and be accountable to them. Second, the legislation would improve the beneficiary complaint review process that I think is in desperate need of reform. You may recall that in 2006 we read about the plight of Mr. Schiff. Mr. Schiff went to a QIO and filed a complaint about the care provided to his wife, who died. The QIO in that case was unresponsive to Mr. Schiff. He was forced to take legal action to learn what the QIO found out about his wife's death. He should not have had to do that. After all, he was the one who filed the complaint with the QIO in the first place because he thought that someone did something wrong that lead to his wife's death. It was at that juncture that I learned that the beneficiary complaint review process was too opaque and ineffective. More importantly, beneficiaries were not being properly served. In fact, I came to learn that complainants often do not receive the findings of the investigation conducted by the QIO. Now I ask; what sense does that make? The Continuing the Advancement of Quality Improvement Act would require MPROs to report the investigational findings to the complainant and refer the provider to a QIO for technical assistance and/or the appropriate regulatory body for sanctions. In other words, this part of the bill would bring transparency to a process now shrouded in a cloud of silence. Third, the Continuing the Advancement of Quality Improvement Act would ensure that limited resources go to providers that need them the most. The GAO recently found that QIOs prioritized their assistance to providers who would be easiest to help rather than the providers who were most in need of help. In other words the QIOs decided it was easier to take a B plus student and make them into an A student rather than putting their resources into the D student to bring them up to par. I guess that way they thought that they would look better and more successful. But if you ask me; that is not the best way to spend limited taxpayer resources. Now, this bill will insure that if demand for technical assistance exceeds available resources, the QIOs would give priority to providers that are in rural or underserved areas, in financial need, have low performance measures or have a significant number of beneficiary complaints. In other words the help is going to go to those who need it most. Fourth, the Continuing the Advancement of Quality Improvement Act would make QIO data more available to CMS and providers for quality improvement and patient safety purposes. Amazingly enough, QIOs are currently restricted from sharing such data despite the obvious value of this data for improving health care quality. This legislation would permit the sharing of QIO data with providers for quality improvement and patient safety purposes and require CMS to make recommendations on how to improve the data sharing process. Fifth, the Continuing the Advancement of Quality Improvement Act would promote competition in the QIO program. This is a giant leap forward. These organizations are currently not subject to significant competition because of limitations on who can be a QIO and the availability of noncompetitive contract renewals. This lack of competition has led to a gross lack of accountability and stagnation in the QIO program. This legislation would promote competition by allowing other types of organizations to serve as QIOs and eliminate noncompetitive renewals. Sixth, the Continuing the Advancement of Quality Improvement Act would enhance governance at the QIOs. During the course of my investigations I identified repeated failures in governance. I exposed board members who were more interested in helping themselves than helping others. This bill will also address board member conflicts of interest. My investigations identified numerous incidents of questionable QIO governance practices and board member conflicts of interest. Since the QIO program receives over $400 million in taxpayer funding every year, it is reasonable for us to expect not only that QIOs are governed in an ethical manner free of conflicts of interest, but also that CMS appropriately oversees the program. This legislation would require QIOs to comply with board governance requirements and would require CMS to establish procedures to address conflicts of interest and follow those procedures. Finally, the Continuing the Advancement of Quality Improvement Act would increase much needed accountability in the QIO program. The I0M, the GAO and the HHS OIG have all questioned the effectiveness of the QIO program. This legislation would require the Secretary to perform interim and final evaluations of program effectiveness not only at the individual QIO level, but at the overall QIO program level as a whole. Also, high performing QIOs would receive financial rewards while low performing QIOs would receive financial penalties. Finally, the Secretary would be required to submit a more detailed annual report showing performance results of QIOs and MPROs and details on how taxpayer dollars are spent. We have been placing more emphasis on the quality of care that our Medicare beneficiaries receive from providers. You see this as we require more transparency in the Medicare program with the public reporting of provider quality measures. You also see this as we transform Medicare from being a passive payer of services of any quality to a value-based purchaser. These are important reforms that will help improve the quality of care provided in the Medicare program and work toward ensuring that limited resources are used more efficiently and wisely. As we move toward a payment system based on quality, the reforms in this bill will position the QIO program to support that transformation in Medicare to a quality-based purchaser by making the tools and assistance available to help Medicare providers improve the quality of the care they provide. The Continuing the Advancement of Quality Improvement Act would ensure the QIO program's ability to provide this assistance in an effective, efficient and accountable manner and correct the problems currently plaguing the program.

Mr. GRASSLEY. Mr. President, I am pleased to join my good friend and colleague Senator Baucus, as well as Senators Lincoln, Roberts, Conrad, Enzi, Schumer, Cochran, Salazar, Smith, Bingaman, and Snowe, to introduce the Pharmacy Access Improvement Act. I am pleased with how well the Medicare Part D program is working. It has demonstrated how effectively private sector competition can work in delivering an entitlement benefit. The program has defied official predictions and come in under budget by $113 billion compared to the baseline projected in 2006. Premiums, initially estimated at $37 for 2006, in fact averaged $23; in 2007 they fell to an average of $22. We understand that this year's bids are even lower and that premiums are expected to fall again next year. The vast majority of Medicare beneficiaries have enrolled in the program, and while there were some troubling start-up problems initially, beneficiaries are very pleased with their plans. At the same time, the first years of implementation of the Part D program have revealed some areas in which the program can be improved. One is related to pharmacy participation in the program. Changes are needed to ensure that Part D treats pharmacies as Congress intended and to make the program friendlier to pharmacists and independent pharmacies. As Senator Baucus, Senator Lincoln, and my other colleagues and I talked to beneficiaries, pharmacists, pharmacy owners and prescription drug plans about changes that would make Medicare Part D work better, many of our discussions centered around how to make sure that Part D works not just for the beneficiaries, the chain drug-stores, and the plans, but also for the local, independent pharmacies, the long-term care pharmacies, and the safety net pharmacies that many beneficiaries rely on. That is exactly what this bill is intended to do. My colleagues and I hope with this bill to improve contracting for pharmacies, increase CMS's and prescription drug plans' customer service, and give beneficiaries better access to pharmacies. Let me give you some of the specifics of the bill. First, the Pharmacy Access Improvement Act would strengthen standards for ensuring convenient beneficiary access to pharmacies. During the first two years of implementation, CMS has permitted some plans to meet the pharmacy access requirements in the law by counting non-preferred and out-of-network pharmacies. The plans charge higher cost-sharing at these pharmacies to discourage their use and drive utilization to preferred pharmacies. Counting non-preferred and out-of-network pharmacies to meet the access requirements is clearly not what Congress had in mind in establishing the beneficiary access guarantees in the law. To correct this problem, this bill would require that plans, with certain exceptions, count only ``open'' pharmacies, those that are accessible to the general public, in meeting the Medicare pharmacy access standard. It also would require plans to count only their preferred in-network pharmacies, not the non-preferred pharmacies, in determining whether they meet the access standard. The bill would allow pharmacies to initiate negotiations with plans under the ``any willing pharmacy'' provision regardless of whether they had already rejected, or failed to act on, previous offers from the plan. The bill also would help ensure the inclusion of safety-net pharmacies in a prescription drug plan's network by preventing plans from specifically excluding 340B entities in the terms of their contracts. 340B entities include federally qualified health centers, migrant health centers, health centers for residents of public housing, school health centers, as well as black lung clinics, entities receiving grants for early intervention for HIV under the Ryan White Act, disproportionate share hospitals, and others. They serve more than ten million people. Many of these entities operate their own pharmacies, which operate under different constraints than other retail pharmacies. They may have abbreviated hours or be available only to patients of the 340B entity. If 340B entities' pharmacies are not available as in-network pharmacies in Part D, these patients may have difficulty getting their prescription drugs. The Model Safety Net Pharmacy Addendum was developed by the Centers for Medicare and Medicaid Services and the Health Research and Services Administration to facilitate 340B entities' participation in Medicare Part D. Because it takes the 340B entities' special circumstances into account, it has appropriate contract language for Part D plans to use when contracting with safety net pharmacies. Under the bill, plans would have to apply the Model Safety Net Pharmacy Addendum to their contracts if a 340B entity so requests. The bill also would require plans to include a contract provision to allow these safety net pharmacies to waive cost-sharing if the entity so requests. Many safety-net pharmacies waive cost-sharing for their patients, but the Part D plan contracts typically prohibit this. Given that 340B entities serve low-income and poor populations, we believe those entities should be able to waive cost sharing for drugs, and our bill would facilitate that. We have found that long-term care pharmacies similarly operate under conditions different from those of retail pharmacies serving the general population. For institutionalized populations, each resident's daily drugs must be specially packaged to help ensure that each gets the drugs meant for her, not for other residents. Long-term care pharmacies specialize in this, but the Part D rules to date do not adequately reflect how long-term care pharmacies work with long-term care facilities, which affects residents' access to these pharmacies. Our bill would require the Secretary to establish rules that include pharmacy access standards for long-term care residents. Another problem that has arisen in the implementation of Part D concerns the ability of beneficiaries to obtain extended supplies of their drugs from a local pharmacy. Our bill therefore would ask the Secretary to establish standards for access to pharmacies that dispense extended supplies of covered drugs. We have also heard from our local independent pharmacies that many, despite contract terms, face delayed payments from prescription drug plans. Given that the pharmacies must pay for their drugs on a more abbreviated schedule, these delays have created cash-flow crises for some pharmacies and put some at risk of closing. As much as I hate to legislate contract terms, I would hate more for the independent pharmacies in my State to close and my beneficiaries to be left without a pharmacy. In our bill, we would require plans to pay most pharmacies within 14 days upon receipt of an electronically submitted clean claim. For paper claims, they would have 30 days. If they were late, the prescription drug plans would have to pay the pharmacies interest. If a pharmacy submitted claims electronically and requested electronic payment, the plan would have to pay electronically. Because long-term care pharmacies operate under unusual circumstances compared with retail pharmacies, our bill would allow pharmacies in long-term care facilities, or that contract with long-term care facilities, at least 30 days but no more than 90 days to submit their claims for reimbursement to the plans. Another problem involves how plans use maximum allowable prices as the upper limit of what they will pay a retail pharmacy for the cost of a drug. What has come to light is that some plans will not disclose to the contracting pharmacies exactly what the maximum allowable prices are either when the contract is proposed to them or even after they sign the contract. It seems unconscionable to me that a pharmacy would be expected to sign a contract where the price term is hidden and not disclosed. In the Medicare program, no other health care providers are subject to signing a contract in which they don't know what they will get paid. Another abusive practice by some plans occurs when they do not update their maximum allowable prices in a timely manner. When a pharmaceutical company raises its price for a drug the pharmacy has to pay that new higher price right away. But the plan might not update what it pays for weeks. That leaves the pharmacy to absorb the difference. The plans that do this know exactly what they are doing. They know they are making the pharmacies eat the higher cost while they delay updating their payment rates. To address these concerns, the bill would require plans to disclose to pharmacies their ``maximum allowable cost'' pricing, and also to update those prices as they change, through an Internet website and a toll-free phone number. Similarly, the bill would require plans to update their prescription drug pricing standard at least every seven days. The drug pricing standard changes frequently, and the price the pharmacy is paid is based on that standard, and so it seemed fair to us that the prescription drug plans' payments should reflect recent changes. Our bill is intended to improve CMS's and prescription drug plans' service to pharmacies. It would require the HHS Secretary to establish a pharmacists' toll-free hotline. Prescription drug plans would have to establish separate pharmacists' and physicians' toll-free hotlines, and would have to comply with customer service standards established by the Secretary. We hope this will prevent pharmacists being placed on long holds when they have customers standing at the counter waiting for their drugs. We have some questions about pharmacists' average dispensing fees, and under the bill the HHS Inspector General would conduct a study of dispensing fees, including studying whether the pharmacist is dispensing a standard prescription or an extended one; whether the pharmacist is in a chain store or an independent pharmacy; whether the pharmacy dispenses specialty pharmacy products, or is a long-term care pharmacy. The Inspector General's report would be due October 1, 2008. I believe that with these changes, the Medicare Part D program will work even better for beneficiaries and for the pharmacies that serve them. As we refine the Medicare Part D program, we want to build on its success even as we hope to make it fairer to all the stakeholders involved, the beneficiaries, the pharmacies, the PDP plans, and the manufacturers. I believe this bill does just that.

Mr. GRASSLEY

Mr. GRASSLEY. Mr. President, my comments here today are to point out the importance of the crop insurance program to America's farmers and America's rural communities. Congress enacted legislation in 1980 that allowed for the expansion of the program and the involvement of the private insurance sector in the crop insurance program's delivery. Since this time, the program has grown from a small, experimental program to one that insures over 70 percent of the eligible acres in the country. In many States, an even higher percentage of the eligible acres in the State are insured. In my home State of Iowa we have over 90 percent enrollment. This protection has come to be relied on by farmers and their lenders as a vital and necessary part of farming. For most farmers their crop insurance policy is the basis of their risk management, crop marketing and loan collateral. The success of the crop insurance program can be attributed to two key items. One is the support of the Federal Government. It is no secret that the Government supports the crop insurance program with premium subsidies that encourage farmers to purchase coverage and help pay for its cost. Additionally, rather than further increasing farmers' premium costs, the Government also pays for the delivery of the program. These Government expenditures, while not insignificant, are considerably less than the Government would likely spend in after-the- fact disaster aid if farmers didn't use the program or if the program didn't exist. The second key item that has contributed to the success of the crop insurance program is the delivery of the program by the private insurance sector. Delivery of the crop insurance program by private companies, using local insurance agents, using modern technology, and with an incentive to do things right and earn underwriting rewards, has allowed for market penetration that was thought impossible by many. But it has occurred, and it continues due to the quality, timely and accurate service being provided to farmers by local agents and companies. I point out the importance of this program and its successes today, because this body is expected to consider this program during debate of the farm bill. It appears that despite successfully operating under separate legislation for years, the crop insurance program is being pulled into the farm bill discussions. The House farm bill has pulled money from the crop insurance program to offset other spending. I intend to analyze carefully the impact this House action will have on farmer's ability to manage their own risk. While I recognize there are improvements that need to be made to the program, crop insurance brings more stability to rural America. American farmers deserve a safety net that they can count on each and every crop year. As the Senate prepares to work on our farm bill provisions, I hope we recognize that crop insurance has become ingrained into the fiber of American agriculture, from the farmers and lenders that depend on it to the rural communities whose local economies are bolstered by it in hard times.

Mr. GRASSLEY

Mr. GRASSLEY. I would thank the distinguished majority leader too because he allowed this process to work. All the amendments that needed to come up--and there was kind of a convoluted way of putting it together with the tax bill that opened up a lot of other avenues and amendments that were brought up. But it really worked out well, and it is in the tradition of the Senate, and I thank you very much for your leniency in regard to letting everything that needed to be discussed, be discussed. I appreciate that.